- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,166.29 / $5,463.36 / $13,841.56
| Facility | | $2,166.29 | $5,463.36 | $13,841.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.91 / $217.82 / $860.00
| Professional | | $108.91 | $217.82 | $860.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,616.14 / $6,256.05 / $11,744.20
| Facility | | $4,616.14 | $6,256.05 | $11,744.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $241.68 / $1,242.00 / $4,406.00
| Facility | | $241.68 | $1,242.00 | $4,406.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,031.00 / $1,775.00 / $4,406.00
| Facility | | $1,031.00 | $1,775.00 | $4,406.00 |